The Motions

I haven’t been writing much lately. I’ve been working a lot, doing lots of calls, but nothing I haven’t done before. I’ve been trying to follow my renewed anti-whine, anti-complaint, try to be an easy going nice guy policy. I’ve had a fair amount of success. It is much less tiring going with the flow than constantly complaining. Want to go to the farthest hospital? Fine. Don’t want to give me your social security number, no problem. Complaining about being cold even though you are already bundled up, here’s another blanket. Not comfortable, let me get you more comfortable? You want me to do transfers all day while you send basics on codes? Fine, as long as my pay check is good at the bank. You want me to go on a priority for a psych because we have a long response because we were three towns away when you gave us the call, fine, I’m just not turning my lights on. Sorry about that one. You called an ambulance for a runny nose, okay, what hospital do you want to go to?

I come to work on time, I check my gear, and I do my job. ABCs, head to toe, vitals, IV, 02, monitor. Write up my report. Sign here. Good luck. Hope you are feeling better. You are very welcome. It’s not bad work.

Baby Medic has a new post. Sailing Rough Waters After six months of being a medic, he is starting to get in a routine and is worried because he is no longer on edge about each call, he is losing his edge. By no longer looking for zebras in the low priority routine call, he is worried he might miss something important. I enjoy reading his posts because it reminds me of my own past and often causes me to question my present.

The ebbs and flows of a medic’s excitement toward the job always fascinate me. What causes burnout? What motivates excitement? I often feel that lately I have just been going through the motions. But I really think now that there is nothing wrong with that. When I started it was very important that I get everything right – that I not miss anything. And while I still don’t want to miss anything and kick myself when I do, I am less concerned about getting the diagnosis right. It is less important that I know exactly what is going on, than that I treat the patient appropriately or appropriately don’t treat. I know now that in many cases it is mostly beyond us to know what is wrong. That’s what they do at the hospital. They have lab tests, X-rays, MRIs and a host of other technological tests and medical experts that help them pinpoint what is really going on. And even then, they might not be able to figure it out. This is particularly true with many of the patients I have who are old and sick. An EMT asked me what I thought was wrong with one elderly patient, and my answer was just that, “She’s old and sick.” I find no shame in telling the nurse, “I don’t know what’s going on. It might be CHF, it might be COPD. It could be pneumonia or a combination of the 3.” Better that than to insist it is CHF and give them lasix and have it turn out to be pneumonia. Do no harm.

I heard a funny joke recently: An internist, a surgeon and an ED doctor are out duck hunting. Five birds fly by. The internist raises his rifle, follows the flock, but doesn’t shoot. Why didn’t he pull the trigger? He is asked. “I’m not certain if any of them were ducks,” he responds. “I need to do more tests.” Then another flock flies past. The surgeon raises his rifle and takes one shot, knocking a single bird from the sky. “How do you know that was duck? The internist asks. “Never question me,” the surgeon says. “It was a duck.” Then another flock flies past. The ED doctor raises a shot gun and shoots from the hip. All five birds drop from the sky. The internist and surgeon look at the ED doctor and say, “What are you doing?” “I don’t know about all of them,” the ED doctor says, “But one of them was definitely a duck.”

The idea being that in emergency medicine you sometimes have to fire everything you have to get the job done, to kill the duck.

That may be true when the patient is circling the drain, but for most of our patients as paramedics, it is not important that we cure them, that we kill the duck.

I view my calls now in different categories. There are calls where I have to do something (meaning provide a treatment) and calls where I don’t. There are obviously some calls where you need to act aggressively to save the patient’s life, when you have to kill the duck. You have to not only think critically, you have to be fast and successful in your skills. These include cardiogenic shock, acute respiratory failure, any unstable airway call, and sudden anaphylaxis. Then there are the routine critical calls – asystolic cardiac arrest, ST elevation MI with stable or stroke with patent airway and stable vitals — where you need to know what you are doing, but you are basically following an established algorithm.

In the non-critical category, there are as well those you treat to stabilize (hypoglycemia, asthma, etc) and those you merely assess and transport (weakness, for example). And there are those you merely provide comfort (morphine for the woman with the broken hip, Zofran for the man with nausea/vomiting).

I think as important a skill for a paramedic as figuring out what is going on with a patient is the ability to see that the patient gets the proper attention at the hospital. This is probably only true for large hospitals, but a paramedic can make a huge difference in whether or not that patient with the hidden MI masking as weakness gets put in a medical alert room or a hallway, that a trauma patient without a mark on him (but a lacerated liver)gets the full work up in the trauma room or again the hallway. It is more important for a medic to be able to say “I don’t know what is going on with this patient, but they need to be seen right away,” than to be able to definitively say what the diagnosis is.

Going through the motions as a medic is okay — as long as going through the motions means doing your assessments, taking your histories, doing your routine ALS. You do that; your patient will be in good hands.

7 Comments

  • fiznat says:

    Thanks for the comments Peter. It helps quite a bit to hear these points from an experienced medic. It is tough to allow yourself to believe that the diagnosis is not always that important. Especially when that is exactly the first question everyone asks. The patient: “what’s wrong with me,” the physician: “what do you think is going on with him,” etc. …But the truth really is that often it does not matter, at least for the time that we spend with the patients.For me this is at once a relief and a bit of a stressor, because on the outset it seems to make the job easier, while at the same time I feel (rightly or not) like I am less of a “healthcare provider” because of it. Medicine seems to revolve around the diagnosis, but then again, maybe experience will teach that this is not quite the case. This is a good topic. Again– thanks for continuing the discussion.

  • Anonymous says:

    I thought if you gave Lasix to someone with pneumonia it dried out their lungs and exacerbated their condition?

  • PC says:

    First on the lasix, my point was you didn’t want to give lasix to someone who turns out to have pneumonia. Better to do no harm by withholding the Lasix, then to give it to the wrong patient.On fiznat’s comments, I don’t mean to imply that diagnosis is not important, it is just that so often we are just guessing, and also our diagnosis is often just a clinical impression of an event as opposed to a true diagnosis. We can say they are in heart failure, but there could be a hundred things causing the failure that we can’t possible figure out. I can write vasovagal syncope for a patient who passed out, but what really caused it. People are so complex, and particuarly the elderly have such a web of chronic diseases and degredations of time attacking them that to really know what the problem is other than age, is hard. Every organ in the body is failing to some degree through age and disease. I often have repeat patients and I ask them what the doctor told them happened the last time, and I often get the answer, they did a lot of tests, but they don’t know what is wrong. It is hard to expect us to be right. All we can really try to do is allievate the symptoms so they are stable without harming them. It doesn’t mean we are not health care providers, and rather advanced ones. Our area is a small one in the larger realm of medicine.

  • Below Average Medic says:

    Yeah, that lasix to a pneumonia patient is a curious deal. I think it’s for that reason we have lasix only after OLMC consent and not standing orders.Another fine one that I’ve done: ß2 agonists to a pulmonary edema patient. Very rapid onset pulmonary edema secondary to an MI. Oops. I had a few calls recently where the patient was pretty adamant about not going to the hospital. Personally, I just like to take people by hook or crook. So I always try to convince them to go.I ended up telling one person, “Look man, I just don’t know what is going on with you. Something isn’t right. I don’t get a good feeling. But whatever happens to be going on puzzles me. I don’t have the tools or the training to tell you what the problem is. The hospital does.”Initially, I was a little apprehensive about being so forthright in telling them that I have no clue what the hell is going on. Fear of being viewed as a retard I guess. But it has helped. When you admit honestly that you don’t have the answers, people are pretty okay with that. Sometimes I’ll ask the ER doc, “What’s going on with this patient.” He or she will reply, “I dunno. We need to run some tests.”

  • Medic09 says:

    Excellent post, and an appropriate perspective from what I can tell.Sometimes folks ask what I do, and I honestly say “I don’t know, it varies a bit, but I always get a chance to be kind.” Some days, that’s the biggest challenge. I can do the ‘motions’ (respiratory or cardiac or pain care, etc.), but do I have the tools to make the patient feel a little more secure, like this will be a little less of a bad day than it started to be?I have found that true in combat medicine, flight medicine, and my routine ‘I stubbed my toe’ 911 calls. I found I have needed it when strapped to a stretcher and being hustled out of harm’s way.What a job. 🙂

  • FireResQGuru says:

    Very true! Sometimes, you simply don’t know what is wrong eith the patient. What I hate more than anything is when you are doing your assessment, getting your history, meds, allergies, etc, and you do your appropriate treatment for what they tell you & what you see…. and then you get to the ER and the patient gives completely differnt information & symptoms to the ER nurse or Doc after you’ve given your report. That’s frustrating as all hell. But I agree, sometimes you don’t know, and shouldn’t be afraid to say you don’t know. Showing care & compassion to the patient, listening to them & comforting them sometimes is more than enough.

  • Chrysalis Angel says:

    I loved this post. I think you explained yourself perfectly. I hope you don’t mind my popping in and out to read, and occasionally leaving you a comment. I enjoy your blog and your perspective.

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